K., Estate of

(SSA Office of Hearings & App. Sept. 21, 1994). ; Clearinghouse Number: 50309

Description

Substantial Compliance with Regulations Entitles Claimant to Reimbursement for Skilled Nursing Facility Care

Abstract

The ALJ has held that, although claimant did not strictly comply with Medicare regulations concerning the date of her admission to a skilled nursing facility (SNF), her "substantial" compliance with those regulations was sufficient to entitle her to coverage. Under 42 C.F.R. § 409.30(b)(1), Medicare covers SNF care only if the beneficiary enters the facility within 30 days of discharge from the hospital. Claimant was initially discharged from the hospital to her home. Within the 30-day period, she sought admission to an SNF; however, for lack of certified beds, she was not admitted until 32 days after her hospital discharge. The intermediary denied payment on the grounds that the late admission posed an absolute bar to Medicare eligibility. Reversing, the ALJ held that it would be unjust to penalize claimant because of a two-day delay that was out of her control. After review, the Appeals Council found that the only exception to the 30-day limitation, 42 C.F.R. 409.30(b)(2), allows a longer period if the patient's condition makes it medically inappropriate to begin an active course of treatment at an SNF and it is medically predictable at the time of hospital discharge that the patient is to require covered care within a predeterminable time period. The Appeals Council remanded for a determination of whether claimant met the exception. On remand, the ALJ held that, although claimant did not meet the exception, she had substantially complied with the 30-day admission rule and therefore was entitled to coverage. The ALJ found abusive and outrageous the benefit payment denial based on the two-day delay in this case.

Additional Information

Attorney Information
Appellant represented by Karyn Rotker, Victor McHenry, Elderly Advocacy Project, Legal Action of Wisconsin, 230 W. Wells St., Milwaukee, WI 53203, (414) 278-7722.
Docket Date
1994-09-21 00:00:00+00:00